959928

editorial2020
JVA0010.1177/1129729820959928The Journal of Vascular AccessBertoglio

Editorial
JVA The Journal of
Vascular Access

The Journal of Vascular Access

Extending the interval of flushing

1­–3
© The Author(s) 2020
Article reuse guidelines:
procedures of totally implantable sagepub.com/journals-permissions
https://doi.org/10.1177/1129729820959928
DOI: 10.1177/1129729820959928

vascular access devices in cancer journals.sagepub.com/home/jva

patients: It is time for a change

Sergio Bertoglio1,2

Abstract
Several recent literature reports regarding the flushing technique of TIVADs highlight how the definition of the optimal
flushing interval is still a source of controversy. Several recent studies indicate more and more frequently how 4 weeks
can be considered a too short interval for the flushing of a totally implantable access device (TIVAD); on the other
hand most of the main guidelines and instructions for use provided by the device’s manufacturers still suggest an
interval between 4 weeks and 1 month as the ideal one. The recent meta-analysis by Wu et al. on this topic, promotes
an important strategy change, indicating the possibility of extending the flushing intervals at least up to 8 weeks. This
editorial extensively discusses the flushing methods of TIVADs highlighting the need for important and substantial
changes, both in extending the range of flushes and in the solutions and methods to be used. It represents an invitation
to the scientific community and device manufacturers for a complete revision of the indications on flushing techniques.

Keywords
Oncology access, techniques & procedures, nursing, central venous access, flushing

Date received: 14 July 2020; accepted: 20 August 2020

The recent meta-analysis on the prolonged flushing time of
totally implantable vascular accesses (TIVAD) by Wu et al.
published in a recent issue of JVA1 offers an interesting
point of discussion with important clinical implications
regarding the management of TIVADs. The flushing
modalities of these devices, performed to maintain long-
term catheter patency and their correct functioning is still a
controversial aspect of maintenance and nursing proce-
dures, are still controversial. A correct TIVAD flushing pro-
cedure is mainly based on three aspects represented by the
type of solutions used, the technique used when performing
the flushing itself and the correct definition of the optimal
times to ensure correct functionality of the devices. TIVAD
flushing procedure is based on three main aspects: the used
solution, the technique of flushing, and the interval of time.
In the last decade, the attention of researchers has mainly
been focused on identifying the best possible applicable
solution for this procedure and on defining a correct execu-
tion technique. Several clinical studies published in the lit-
erature2–5 and the latest international guidelines have
established that, as far as non-dialysis catheters (NDCVA)
are concerned, the standardized use of normal saline solu-
tion is to be preferred to anticoagulant solutions and, in par-
ticular, to heparinized saline solutions. In particular, the
recent INS 2016 Standard of Practice and the Gruppo
Accessi Venosi Centrali a Lungo Termine (GAVeCeLT)
2016 consensus of Italian experts have given clinical
importance to this topic suggesting that normal saline solu-
tion is to be preferred in lieu of heparinized saline solution
significant clinical relevance regarding the topic and sug-
gest that normal saline solution is to be preferred in lieu of
heparinized solutions, which, for the latest decades, have
been considered a standard of practice.6,7 The rationale of
these positions are based on safety reasons, clinical effi-
cacy, economics, and ease of use; all of which having and
1
Department of Surgical Sciences, University of Genova, Genova, Italy
2
Chirurgia 1 – Policlinico San Martino, Genova, Italy
Corresponding author:
Sergio Bertoglio, Department of Surgical Sciences, University of
Genova, Viale Benedetto XV 10, Genova 16100, Italy.
Email: scotchbertoglio@gmail.com
2 The Journal of Vascular Access 00(0)
these recommendations have relegated the use of heparin
solutions to a marginal and almost obsolete role with the
exclusion of venous catheters used in nephrology patients
for dialysis purposes. Similarly, there is a large consensus
in the literature relating to catheter flush technique perfor-
mance which must absolutely be pulsatile and with a posi-
tive pressure over the syringe piston, paying particular
attention to the prevention of blood reflux in the tip of the
catheter at the end of the wash injection.8,9
The innovative aspect of Wu et al.’s recent meta-analysis
concerns the timing for flushing TIVADs, especially when
they are dormant or not in use, and/or when their removal is
contraindicated. Scientific research has been manifestly
lacking or of little incisiveness regarding this topic. For sev-
eral decades now, the main guidelines relating to long-last-
ing vascular access have always indicated an interval
ranging from 4 weeks to a month as the optimal timing for
flushing procedures and control of catheter patency.
Moreover, almost all of the medical industry involved in the
production of TIVADs specifically suggest the adoption of
this interval in the device instructions for use (IfU). Not eve-
ryone, however, agrees with this position and there is litera-
ture, albeit scant, which has long suggested that this interval
could be prolonged without compromising the correct effec-
tiveness of the devices or causing more mechanical compli-
cations, such as occlusion. Unfortunately, these are sporadic
reports and tend to be occasional observations or, in some
cases, random results relating to clinical errors in the plan-
ning of maintenance of TIVADs or failure of patients to
comply with medical prescriptions.5
However, it is also well known that in many hospitals,
especially in cancer centers where patients cyclically refer
to outpatient facilities, an explicit custom of extending
this time interval to at least 2 months is adopted quite
often.10–13 This practice, albeit in open violation of what is
expressed by numerous guidelines and by the main IfUs
of the devices, finds a strong rationale in terms of: patient
compliance and improvement of quality of life; difficulty
in accessing healthcare facilities in low-intensity geo-
graphical areas of care; and, last but not least, a clear sav-
ings economically economic savings.
In over 10 years of our personal experience at a high
intensity cancer hospital, the flushing time interval for
TIVADs not in use has been extended to 2 months without
negative effects in terms of increased mechanical compli-
cations or intraluminal occlusion of the devices. It should
also be noted that, between the beginning of March 2020
and the end of June 2020, in conjunction with the recent
Covid-19 COVID-19 pandemic, this interval was further
prolonged to up to 3 months in over 200 patients. The
rationale for this choice was to ensure fewer patients
accessing hospitals, thus, minimizing the risk of transmis-
sion of Sars-Cov-2SARS-CoV-2. During this period there
was no noted increase in the mechanical and occlusive
complications of TIVADs. In our experience, the Covid-19
COVID-19 pandemic has provided an excellent opportu-
nity to implement into clinical practice the conclusions of
Wu et al. meta-analysis and to confirm the assumption that
prolonging the flushing interval of TIVADs can be an opti-
mal clinical strategy without negative outcomes.
To reinforce this belief, it is worth mentioning Wu
et al.’s meta-analysis observation that in patients whose
flushing interval of TIVADs had been prolonged up to
8 weeks, the incidence of major adverse events or occlu-
sion of the catheters was lower than that reported for
patients with flushing interval of 4 weeks. Therefore, the
prolonged frequency of flushing to at least 8 weeks, and
perhaps beyond, has little effect on the mechanical and the
occlusive complications of the catheters. This can be fur-
ther ensured by means of correct washing methods and the
use of suitable solutions such as normal saline.
It is therefore intuitive to conclude that the time has cer-
tainly come to bring forth a decisive change in the flushing
strategies of the TIVADs based not only on the type of
solution to be used and the importance of a flushing the
device correctly, but also for the adoption of a policy to
prolong the flushing time interval to at least 2 months. A
further flushing interval extension to 3 months could even
be considered possible, but must be investigated with fur-
ther clinical trials.13,14
Like any change in entrenched habits, a proactive effort
by the scientific community and the medical industry is
advisable to achieve widespread propagation of flushing
procedure changes within the medical community. Given
these revelations, the manufacturers of TIVAD could
review the contents of their IfU for these devices. It would
be advisable that scientific networks and medical industry
actively participate in this effort to improve patient com-
pliance, safety and efficacy of vascular accesses.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Sergio Bertoglio https://orcid.org/0000-0001-7235-3444
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